What is the treatment for vestibular migraine?

Treatment of Vestibular Migraine

The treatment of vestibular migraine should follow a stepped approach, with beta blockers (atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan as first-line preventive medications for patients experiencing symptoms on ≥2 days per month despite optimized acute treatment. 1

Acute Treatment

Acute treatment aims to reduce symptoms during vestibular migraine attacks:

1. First-line options:

   • NSAIDs with antiemetics if necessary 1
   • For severe attacks or when NSAIDs fail after three consecutive attacks:
     • Triptans (sumatriptan, rizatriptan, zolmitriptan) 1, 2
     • Consider non-oral formulations if nausea/vomiting is prominent 1

2. Second-line options:

   • Antiemetics (dimenhydrinate, metoclopramide) 3, 4
   • Vestibular suppressants (meclizine, diphenhydramine) 3
   • Benzodiazepines (for severe vertigo) 4

Preventive Treatment

Preventive treatment should be considered when:

• Patient experiences ≥2 days per month of vestibular migraine symptoms despite optimized acute treatment 1
• Attacks are frequent or disabling 2

Medication Options:

1. First-line preventives:

   • Beta blockers without intrinsic sympathomimetic activity (atenolol, bisoprolol, metoprolol, propranolol) 1, 2, 4
   • Topiramate 1, 2, 3
   • Candesartan 1

2. Second-line preventives:

   • Flunarizine 1, 3
   • Amitriptyline 1, 2, 3
   • Venlafaxine 2
   • Sodium valproate (contraindicated in women of childbearing potential) 1, 3

3. Third-line preventives:

   • CGRP monoclonal antibodies 1
   • For refractory cases: acetazolamide or lamotrigine 2, 4

Non-pharmacological Approaches

These can be used as adjuncts to medications or as stand-alone treatments when medications are contraindicated:

1. Evidence-supported options:

   • Vestibular rehabilitation (particularly beneficial for elderly patients) 1, 5, 4
   • Non-invasive neuromodulatory devices 1
   • Biobehavioral therapy 1
   • Acupuncture 1

2. Lifestyle modifications:

   • Regular physical activity (cardio-exercise for at least 30 minutes twice weekly) 5
   • Stress management and relaxation techniques 3
   • Trigger avoidance 1
   • Home safety assessment to prevent falls 5

Special Populations

Children and Adolescents

• Ibuprofen is recommended for pain management 1
• For adolescents, consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 1
• Preventive options include amitriptyline (especially when combined with cognitive behavioral therapy), topiramate, and propranolol 1

Older Adults

• Exercise caution with triptans due to potential cardiovascular risks 1
• Monitor blood pressure regularly in patients using triptans 1
• Consider vestibular rehabilitation in addition to pharmacological treatment 5

Treatment Algorithm

1. Start with acute treatment:

   • NSAIDs + antiemetic for initial attacks
   • If ineffective after three attacks, switch to triptans
   • If one triptan fails, try another or a NSAID-triptan combination

2. Initiate preventive treatment if:

   • Symptoms occur ≥2 days/month despite optimized acute treatment
   • Attacks are frequent or disabling

3. Select preventive medication based on:

   • Comorbidities (e.g., avoid beta blockers with asthma)
   • Contraindications (e.g., avoid valproate in women of childbearing potential)
   • Start with first-line options before moving to second or third-line

4. Add non-pharmacological approaches:

   • Vestibular rehabilitation
   • Lifestyle modifications
   • Stress management techniques

Common Pitfalls and Caveats

• Vestibular migraine is often underdiagnosed and undertreated 6
• Distinguish from other conditions like Meniere's disease, which has similar symptoms but includes hearing loss 2, 6
• Limited high-quality randomized controlled trials exist specifically for vestibular migraine treatment; most recommendations are adapted from general migraine treatment guidelines 3
• Prognosis may be less favorable for vestibular migraine than for migraine headaches 3
• Patients should be reassessed within one month after initial treatment to confirm symptom resolution 5

By following this evidence-based approach to treating vestibular migraine, clinicians can help reduce the frequency and severity of attacks while improving patients' quality of life.